Order no. 22
The case of the complainant in brief is that the complainant’s husband had Senior Citizen Red Carpet Policy for the period from 6.6.11 to 5.6.12. He was suffering from back and abdominal pain during the year 2011 and the husband of the complainant underwent treatment at Woodland Multi-speciality Hospital and Right Nephroureterectomy (surgery) was done on 7.11.11 as the husband of the complainant was covered by insurance policy issued by o.p. therefore the complainant submitted a claim to o.p. for reimbursement of the expenses related to the hospitalization of the husband of the complainant. The insurance company rejected the claim vide its letter dt.18.1.12 by stating inter alia that at the time of inception of the 1st policy on 6.6.11 the insured did not disclose the medical history / health details in the proposal form submitted to o.p. insurance company. On the said ground the insurance company repudiated the claim of the complainant.
The complainant thereafter went to Grievance Redressal Officer but no relied was given to the complainant. Subsequently the complainant filed this case praying for the bill amount ofRs.1,55,651/- plus Rs.44,918/- plus 7% interest and also prayed for compensation of rs.5 lakh and litigation cost of Rs.30,000/- in total the complainant claimed Rs.8,66,000/-.
The o.p. contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that the o.p. issued an insurance policy under Senior Citizen Red Carpet Policy being no.P/190000/01/2012/001585 covering the complainant’s husband Sri Gautam Banerjee for the period from 6.6.11 to 5.6.12 for sum insured of Rs.3 lakhs. The husband of the complainant was admitted in Woodland Multispeciality Hospital on 6.11.11 and sought reimbursement for the treatment of Right Ureteric Tumor and it was observed from the records of the hospital and from the investigation report from the hospital record that the patient was admitted there earlier for the same treatment in the hospital which was not disclosed to o.p. at the time of inception of the abovementioned policy. The claim was rejected by o.p. on scrutiny of the medical records on the ground under exclusion clause no.7 of the policy which states that if there is any misrepresentation / non disclosure of the material fact whether by the insured or by any other person acting on his behalf the company is not liable to make any payment. Accordingly the claim was repudiated on 18.1.12. The o.p. after repudiation of the claim returned all the original documents relating to the said treatment to the insured.
The complainant thereafter approached the ld. ombudsmen, Kolkata and demanded a claim of Rs.7 lakhs as compensation which was also rejected with a direction to produce some documents and on failure to produce those documents and the o.p. was directed to consider the claim settlement for Rs.1,02,865/- against the total bill originally submitted for Rs.1,55,651/- and some deduction was made as per the package rate the reasonable and necessarily incurred expenses allowed towards professional fees are Rs.65,000/- against the total bill submitted of Rs.70,000/- and allowed OT charge of Rs.10,000/- by deducting Rs.3000/- against the total bill of Rs.13,000/- and the said deduction was made and some other deductions were also made as per the guideline of IRDA. It was further stated that the insurance ombudsmen after considering all pros and cons of the subject claim allowed the claim of the complainant to the extent permissible in law. The o.p. took all efforts to satisfy the award passed by ld. ombudsmen but could not succeed due to non cooperation of the complainant. As such, there was no deficiency in service on the part of the o.p. In view of the facts and circumstances as state above o.p. prayed for dismissal of the case.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant’s husband had the valid policy at the relevant point of time.
- Whether the complainant made the claim as per the direction of ld. ombudsmen.
- Whether the complainant provided all the original documents in complying with the direction of ld. ombudsmen.
- Whether the complainant received the amount from her employer.
- Whether there was any suppression of material fact on the part of the insured regarding his pre existing disease.
- Whether the complainant will be entitled to get the relief as prayed for.
Decision with reasons:
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
The complainant argued the case by herself. During argument she stated that her husband was a policy holder under the o.p. and during the subsistence of the policy her husband fell ill and he was admitted to Woodland Hospital whereby he underwent an operation and after the recovery of the insured the complainant submitted the medical bills for reimbursement. It was emphasized by the complainant that she submitted the claim to Star Health for reimbursement of the medical expenses and allied insurance company’s agent has helped the complainant for filling up the form and submission of the required documents. He also assured the complainant that the claim will be settled within one month. The claim application along with all relevant bills and documents were submitted and received by o.p. on 11.12.11. the insurance company rejected the claim by issuing a letter stating inter alia that since at the time of inception of the policy the insured had suppressed the medical history which amounts to misrepresentation / non disclosure of material facts. After getting such information from the insurance company addressed the Grievance Redressal Officer but no reply was received and subsequently the complainant was informed that the claim was rejected on account of misrepresentation / non disclosure of material fact. The complainant thereafter moved to ld. insurance ombudsmen who passed an order on 19.2.13 whereby it was stated that the insurance company has agreed to admit the claim. The insurance company after receiving the said order from ld. ombudsmen informed the complainant the insurance company was eager for settlement of original claim amount of Rs.1,55,651/-, but the insurance company did not agree to pay any compensation for harassment caused to the complainant.
Being aggrieved by the decision of ld. ombudsmen and in order to have the compensation the complainant filed this case praying for total claim of Rs.8,66,000/-.
Ld. lawyer for the o.p. argued that the claim of the insured was repudiated initially due to the suppression of the pre existing disease and as per the exclusion clause no.7 of the policy the claim of the complainant was repudiated which was communicated to the insured vide letter 8.1.12. The complainant then asked all the documents from the insurance company and accordingly all the documents were returned to the insured by the o.p. vide letter dt.10.3.12. The complainant demanded compensation of Rs.7 lakhs against the original claim of Rs.1,55,651/- and ld. ombudsmen by an order dt.19.2.13 directed the complainant to comply with the requirements of the insurance company and the insurance company was directed to admit the claim and settle the same as per the terms and conditions of the policy within 15 days from the date of receipt of the award.
After getting the said order from ld. ombudsmen o.p. requested the complainant to submit the original documents and since no action was taken on the part of the complainant another reminder was issued on 19.4.13 in order to release the payment. The complainant replied the said letter stating that the offer of settlement is too little and it was not acceptable for the complainant to accept the said amount. The o.p. informed the said fact to ld. ombudsmen and for which the insurance company could not comply the order as passed by ld. ombudsmen. The o.p. considered the claim for settlement of Rs.1,02,865/- after necessary deduction in respect of the original claim made by the insured to the tune of Rs.1,55,651/-. On the basis of the facts and circumstances of the case and also non cooperation on the part of the complainant for releasing the fund in favour of the insured the delay was committed for which o.p. cannot be held responsible.
Ld. lawyer for o.p. argued that since the complainant was an officer at the relevant point of time and she availed of the medical reimbursement in respect of her husband’s claim and with regard to the said fact the o.p. informed the vigilance department of the bank whereby the complainant was an officer of the said bank and insurance company received an e-mail from vigilance department of UCO Bank, Kolkata whereby it was informed that the bank has passed an amount of Rs.55,054.14 for hospitalization from 6.11.11 to 14.11.11 and she was also further reimbursed of Rs.90,650/- by the bank’s mediclaim partner as per prevailing scheme.
Considering the said fact ld. lawyer for o.p. emphasized that the complainant had received the entire money regarding the medical expenses incurred for the treatment of her husband. Moreover, o.p. was eager to comply the order of ld. ombudsmen but due to non cooperation made by the complainant the said amount was not disbursed. Having regard to the facts and circumstances of the case ld. lawyer for o.p. prayed for dismissal of the case.
Considering the submissions of the respective parties it appears that the husband of the complainant was insured with the insurance company at the relevant point of time. It is an admitted fact that the complainant’s husband had valid policy and during the validity of the policy the insured was admitted to the Woodland Hospital and he had undergone an operation and had been there from 6.11.11 to 14.11.11. It is also found from the materials on record that immediately after the releasing of the insured from the hospital the complainant applied to the o.p. for reimbursement of the medical expenses. The claim was repudiated by o.p. with the plea that the violation of exclusion clause no.7 of the policy. Since the insured had suppressed his pre existing disease and on suppression of the said fact the repudiation was made. The complainant thereafter approached to the customer care of the company and subsequently the complainant prayed to the ld. ombudsmen and from the order of ld. ombudsmen it appears that there was a direction made by ld. ombudsmen for settlement of the claim of the complainant. It is also found from the materials on record that o.p. after getting the order from ld. ombudsmen requested the complainant to provide of the medical papers including vouchers for settlement of the claim. The complainant initially did not reply to the request of the insurance company, subsequently she informed the o.p. that the award given by ld. ombudsmen false short of their expectation as they were made to suffer unnecessarily by the company when the family and the complainant needed the reimbursement for expenses incurred for her husband’s post surgery chemo and radiation therapy. The offer of settling their claim was too little and too late.
After sending the said reply to o.p. the complainant filed this case before this Forum with the claim of Rs.8,66,000/- including the medial expenses incurred by the complainant for the treatment of her husband. From the materials on record it is crystal clear that the insurance company during the process of claim made by the complainant towards the amount claimed by her an e-mail was sent to the vigilance department addressed to G.M. Vigilance, UCO Bank, Kolkata whereby it was stated that Mrs. Maitrayee Banerjee who had been to be General Manger of UCO Bank and retired from services on Feb 2012 and as per record Mrs. Banerjee has preferred an insurance claim in respect of her husband for his admission and surgical procedure at Woodland Hospital Kolkata from 6.11.11 to 14.11.11 amounting to Rs.1,55,651/-. It was also stated in the communication made to the bank that since Mrs. Banerjee was on active service of the bank during the period of such hospitalization of her husband, the insurance company wanted to know whether any medical reimbursement of such account was allowed to Mrs. Banerjee by the bank in order to settle the claim as per rules of the company. The said mail was sent to the bank on 3.2.15.
In response to the said mail a reply was given from the head office, vigilance department, UCO Bank, Kolkata regarding the claim of Mrs. Maitrayee Banerjee whereby it was informed that the bank has passed an amount of Rs.55,054.14 for hospitalization from 6.11.11 to 14.11.11 and she also has been further reimbursement of Rs.90,650/- by the banks mediclaim partner as per prevailing scheme. On relying on the said documents it appears that the bank had already released the amount of Rs.1,45,704.14 out of the total claim amount of Rs.1,55,651/-. It is also relevant to mention here that in spite of direction given by ld. ombudsmen for settlement of the claim and in obedience of the said settlement whenever the insurance company informed the complainant for production of the original documents to settle the claim amount, the complainant did not provide those documents and by suppressing the fact of her getting the amount from the bank towards the claim made by her on production of those documents viz. medical bills the amount was released in favour of the complainant to the tune of Rs.1,45,704.14 the complainant again claimed the said amount and did not cooperate with the insurance company. From the materials on record it appears that the complainant by suppressing the entire fact illegally claimed the amount from the insurance company and also filed this case before this Forum by making false allegation against the insurance company. Therefore we hold that the complainant has already received the reimbursement of the medical bills of her husband, therefore her claim for further reimbursement of the medical bills and also for compensation cannot be entertained and accordingly we hold that the complainant has not come before this Forum with clean hands and she will not be entitled to get any relief as prayed for. Thus all the points are disposed of accordingly.
Hence, ordered,
That the CC No.503/2014 is dismissed on contest without cost against the o.p.
Supply certified copy of this order to the parties free of cost.
